Frequent exacerbator—patient who has experienced ≥2 exacerbations requiring oral corticosteroids and/or antibiotics or one hospitalisation for COPD in the past year

Non-pharmacological management

Assess inhaler use and technique at each stage prior to escalating treatment and opportunistically at every consultation:

monitor inhaler use using repeat prescription history

Discuss smoking cessation at each stage prior to escalating treatment

Encourage patients to identify triggers for exacerbations and encourage self-management based on early recognition of, and actions taken for, exacerbations

Reinforce lifestyle advice on diet and exercise in all patients at every opportunity

Offer pulmonary rehabilitation to all patients depending on local pathways and availability

Long-term oxygen therapy

Multidisciplinary support and treatment for patients with severe disease

Pharmacological management

Check summary of product characteristics before prescribing to rule out contraindications and precautions

Choose short- and long-acting β-agonist (SABA and LABA), short- and long-acting muscarinic agonist (SAMA and LAMA), and inhaled corticosteroid (ICS) according to local formulary

LABA/LAMA combination inhalers are a new drug class that improves lung function, symptoms, and exacerbation rates

Ensure patients have maximal bronchodilation using LABA/LAMA before prescribing ICS. This practice will ensure ICS/LABA use only in patients who are frequent exacerbators despite optimised lung function

Review use of ICS in non-exacerbators:

consider stopping in patients with FEV1 >50% predicted

consider discussing use of ICS in patients with FEV1 30–50% predicted with COPD service

continue ICS in patients with FEV1 <30% predicted

Oral steroids are not recommended for routine use

Follow-up

Ask patients to return if symptoms do not improve or worsen

Review patients at least every 12 months and earlier if they experience an exacerbation

Referral

Refer patients who are still symptomatic on maximal bronchodilation, who are still exacerbating/admitted to hospital on triple therapy, or in whom there is diagnostic uncertainty to local COPD service for confirmation of diagnosis and evaluation of further management options, such as theophylline, mucolytics and antibiotics, which should not routinely be initiated in primary care

Consider early referral of patients with symptoms suggestive of bronchiectasis (e.g. excess sputum or evidence of recurring colonisation) and patients with hypoxaemia.

This algorithm has been developed by MGP Ltd, the publishers of Guidelines, and the expert group was convened by them. AstraZeneca was able to recommend an expert to Chair the group and comment on the scope and title, with final decisions resting with the Chair. AstraZeneca had the opportunity to comment on the technical accuracy of this algorithm but the content is independent of and not influenced by AstraZeneca